Some narcissistic traits are common and a normal developmental phase. When these traits are compounded by a failure of the interpersonal environment and continue into adulthood, they may intensify to the point where NPD is diagnosed.[4] Some psychotherapists believe that the etiology of the disorder is, in Freudian terms, the result of fixation to early childhood development.[5]

A 1994 study by Gabbard and Twemlow[6] reports that histories of incest, especially mother-son incest, are associated with NPD in some male patients.

Theories

Pathological narcissism occurs in a spectrum of severity. In its more extreme forms, it is narcissistic personality disorder (NPD). NPD is considered to result from a person’s belief that they are flawed in a way that makes them fundamentally unacceptable to others.[7] This belief is held below the person’s conscious awareness; such a person would, if questioned, typically deny thinking such a thing. In order to protect themselves against the intolerably painful rejection and isolation that (they imagine) would follow if others recognised their (perceived) defective nature, such people make strong attempts to control others’ views of them and behavior towards them.

Pathological narcissism can develop from an impairment in the quality of the person’s relationship with their primary caregivers, usually their parents, in that the parents were unable to form a healthy and empathicattachment to them.[citation needed] This results in the child’s perception of himself/herself as unimportant and unconnected to others. The child typically comes to believe they have some personality defect that makes them unvalued and unwanted.[8]

To the extent that people are pathologically narcissistic, they can be controlling, blaming, self-absorbed, intolerant of others’ views, unaware of others’ needs and of the effects of their behavior on others, and insistent that others see them as they wish to be seen.[9]

People who are overly narcissistic commonly feel rejected, humiliated and threatened when criticised. To protect themselves from these dangers, they often react with disdain, rage, and/or defiance to any slight criticism, real or imagined.[10] To avoid such situations, some narcissistic people withdraw socially and may feign modesty or humility. In cases where the narcissistic personality-disordered individual feels a lack of admiration, adulation, attention and affirmation, he/she may also manifest wishes to be feared and to be notorious (narcissistic supply).

Although individuals with NPD are often ambitious and capable, the inability to tolerate setbacks, disagreements or criticism, along with lack of empathy, make it difficult for such individuals to work cooperatively with others or to maintain long-term professional achievements.[11] With narcissistic personality disorder, the individual’s self-perceived fantastic grandiosity, often coupled with a hypomanic mood, is typically not commensurate with his or her real accomplishments.

Splitting

People who are diagnosed with narcissistic personality disorder use splitting (black and white thinking) as a central defense mechanism. They do this to preserve their self-esteem, by seeing the self as purely good and the others as purely bad. The use of splitting also implies the use of other defense mechanisms, namely devaluation, idealization and denial.[12]

Relationship to shame

It has been suggested that narcissistic personality disorder may be related to defenses against shame.[13]

Psychiatrist Glen Gabbard suggested NPD could be broken down into two subtypes.[14] He saw the “oblivious” subtype as being grandiose, arrogant, and thick-skinned and the “hypervigilant” subtype as being easily hurt, oversensitive, and ashamed. In his view, the oblivious subtype presents for admiration, envy, and appreciation a powerful, grandiose self that is the antithesis of a weak internalized self, which hides in shame, while the hypervigilant subtype neutralizes devaluation by seeing others as unjust abusers.

Dr. Jeffrey Young, who coined the term “Schema Therapy“, a technique originally developed by psychiatrist Aaron T. Beck (1979), also links NPD and shame. He sees the so-called Defectiveness Schema as a core schema of NPD, along with the Emotional Deprivation and Entitlement Schemas.[15]

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy, beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

Has a grandiose sense of self-importance (e.g., exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements)

Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love

Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high-status people (or institutions)

Requires excessive admiration

Has a sense of entitlement, i.e., unreasonable expectations of especially favorable treatment or automatic compliance with his or her expectations

Is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends

Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others

Is often envious of others or believes others are envious of him or her

Proposed removal from DSM-5

The Personality and Personality Disorders Work Group has proposed[16] the elimination of NPD as a distinct disorder in DSM-5[17] as part of a major revamping of the diagnostic criteria for personality disorders, replacing a categorical with a dimensional approach based on the severity of dysfunctional personality trait domains. Some clinicians have objected, characterizing the new diagnostic system as an “unwieldy conglomeration of disparate models that cannot happily coexist” and may have limited usefulness in clinical practice.[18]

Fanatic narcissist – including paranoid features. An individual whose self-esteem was severely arrested during childhood, who usually displays major paranoid tendencies, and who holds on to an illusion of omnipotence. These people are fighting delusions of insignificance and lost value, and trying to re-establish their self-esteem through grandiose fantasies and self-reinforcement. When unable to gain recognition or support from others, they take on the role of a heroic or worshipped person with a grandiose mission.

Alexander Lowen has also specified five major subtypes from Phallic (“Skirtchasing”) to Sociopathic (i.e., dissociative, capable of mayhem and murder) as outlined in his famous book, “Narcissism: Denial of the True Self”.

Schema Therapy, a form of therapy developed by Jeffrey Young that integrates several therapeutic approaches (psychodynamic, cognitive, behavioral etc.), also offers an approach for the treatment of NPD.[21] It is unusual for people to seek therapy for NPD. Subconscious fears of exposure or inadequacy often cause defensive disdain of therapeutic processes.[22][23]Pharmacotherapy is rarely effective.

Epidemiology

Lifetime prevalence is estimated at 1% in the general population and 2% to 16% in clinical populations.[3][24]

Twenge and Campbell conducted studies suggesting that the incidence of NPD has more than doubled in the US in the last 10 years and now 1 in 16 of the population have experienced NPD.[25]

History

The history of narcissism predates the discovery of narcissistic personality disorder. The term “narcissistic personality structure” was introduced by Kernberg in 1967[26] and “narcissistic personality disorder” first proposed by Heinz Kohut in 1968.[27]

Cultural depictions

In the film To Die For, Nicole Kidman’s character wants to appear on television at all costs, even if this involves murdering her husband. A psychiatric assessment of her character noted that she “was seen as a prototypical narcissistic person by the raters: on average, she satisfied 8 of 9 criteria for narcissistic personality disorder… had she been evaluated for personality disorders, she would receive a diagnosis of narcissistic personality disorder.”[28]

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